I hereby confirm that this is a private car and registered in Peninsular Malaysia only.

Address *

:

Postcode *

:

City
*

:

State
*

:

Contact No.
*

:

(Mobile)

Contact No. - Mobile

Example of acceptable formats:

Mobile

:

0163156089

Home

:

0370818900

Office

:

0370818900

(Home)

Contact No. - Home

Example of acceptable formats:

Mobile

:

0163156089

Home

:

0370818900

Office

:

0370818900

(Office)

Contact No. - Office

Example of acceptable formats:

Mobile

:

0163156089

Home

:

0370818900

Office

:

0370818900

Email *

:

Email

Examples of acceptable formats:

Example 1

:

sidhu@yahoo.com

Example 2

:

john@gmail.com

Example 3

:

myeg@myeg.com.my

Declaration

DECLARATION:By clicking the 'PROCEED' button, I hereby declare that all statements given in this online application are complete and true. This declaration shall form the basis of the contract between me and Zurich Takaful Berhad.